We treated 32 displaced mallet finger fractures by a two extension block Kirschner-wire technique. The clinical and radiological outcomes were evaluated at a mean follow-up of 49 months (25 to 84). The mean joint surface involvement was 38.4% (33% to 50%) and 18 patients (56%) had accompanying joint subluxation. All 32 fractures united with a mean time to union of 6.2 weeks (5.1 to 8.2). Congruent joint surfaces and anatomical reduction were seen in all cases. The mean flexion of the distal interphalangeal joints was 83.1° (75° to 90°) and the mean extension loss was 0.9° (0° to 7°). No digit had a prominent dorsal bump or a recurrent mallet deformity. We believe that this technique, when properly applied, produces satisfactory results both clinically and radiologically

We compared the outcome of closed intramedullary nailing with minimally invasive plate osteosynthesis using a percutaneous locked compression plate in patients with a distal metaphyseal fracture in a prospective study. A total of 85 patients were randomised to operative stabilisation either by a closed intramedullary nail (44) or by minimally invasive osteosynthesis with a compression plate (41). Pre-operative variables included the patients’ age and the side and pattern of the fracture. Peri-operative variables were the operating time and the radiation time. Postoperative variables were wound problems, the time to union of the fracture, the functional American Orthopaedic Foot and Ankle surgery score and removal of hardware. We found no significant difference in the pre-operative variables or in the time to union in the two groups. However, the mean radiation time and operating time were significantly longer in the locked compression plate group (3.0 vs 2.12 minutes, p < 0.001, and 97.9 vs 81.2 minutes, p < 0.001, respectively). After one year, all the fractures had united. Patients who had intramedullary nailing had a higher mean pain score, but better function, alignment and total American Orthopaedic Foot and Ankle surgery scores, although the differences were not statistically significant (p = 0.234, p = 0.157, p = 0.897, p = 0.177 respectively). Three (6.8%) patients in the intramedullary nailing group and six (14.6%) in the locked compression plate group showed delayed wound healing, and 37 (84.1%) in the former group and 38 (92.7%) in the latter group expressed a wish to have the implant removed. We conclude that both closed intramedullary nailing and a percutaneous locked compression plate can be used safely to treat Orthopaedic Trauma Association type-43A distal metaphyseal fractures of the tibia. However, closed intramedullary nailing has the advantage of a shorter operating and radiation time and easier removal of the implant. We therefore prefer closed intramedullary nailing for patients with these fractures

We report the results of a prospective study of the incidence of algodystrophy following Colles' fracture in 60 patients, using sensitive or quantitative techniques for the assessment of each feature of the syndrome. Nine weeks after fracture, 24 patients had evidence of vasomotor instability, 23 had significant tenderness of the fingers and 23 had lost finger movement. These three abnormalities were significantly associated (p less than 0.001). Swelling was also significantly associated with these three variables. There was no statistical association between the occurrence of algodystrophy and the patient's age or sex, the severity of the fracture, the number of reductions performed or the adequacy of the reduction. We conclude that algodystrophy constitutes a precisely definable and quantifiable syndrome which is more common than has been suspected

Intramedullary locking nails have proved to be of considerable advantage when treating complex, comminuted or segmental femoral shaft fractures. We have reviewed 117 patients with 120 femoral shaft fractures treated with the Strasbourg device. These included 20 compound fractures, 13 pathological fractures and two non-unions. Rehabilitation and union rates have been very satisfactory and there have been no serious infections in the series. Comminution of the proximal femur has occurred in six patients and there have been three femoral neck fractures, but all of these have healed without further complications

The aim of our study was to investigate whether placing of the femoral component of a hip resurfacing in valgus protected against spontaneous fracture of the femoral neck. We performed a hip resurfacing in 20 pairs of embalmed femora. The femoral component was implanted at the natural neck-shaft angle in the left femur and with a 10° valgus angle on the right. The bone mineral density of each femur was measured and CT was performed. Each femur was evaluated in a materials testing machine using increasing cyclical loads. In specimens with good bone quality, the 10° valgus placement of the femoral component had a protective effect against fractures of the femoral neck. An adverse effect was detected in osteoporotic specimens. When resurfacing the hip a valgus position of the femoral component should be achieved in order to prevent fracture of the femoral neck. Patient selection remains absolutely imperative. In borderline cases, measurement of bone mineral density may be indicated

The haematoma occurring at the site of a fracture is known to play an important role in bone healing. We have recently shown the presence of progenitor cells in human fracture haematoma and demonstrated that they have the capacity for multilineage mesenchymal differentiation. There have been many studies which have shown that low-intensity pulsed ultrasound (LIPUS) stimulates the differentiation of a variety of cells, but none has investigated the effects of LIPUS on cells derived from human fracture tissue including human fracture haematoma-derived progenitor cells (HCs). In this in vitro study, we investigated the effects of LIPUS on the osteogenic activity of HCs. Alkaline phosphatase activity, osteocalcin secretion, the expression of osteoblast-related genes and the mineralisation of HCs were shown to be significantly higher when LIPUS had been applied but without a change in the proliferation of the HCs. These findings provide evidence in favour of the use of LIPUS in the treatment of fractures

Ninety-eight fractures of the shaft of the femur were seen in one unit over the two years 1974 and 1975, and the results have been assessed in sixty-nine. Of these, thirty-eight were treated by skeletal traction in a Thomas's splint followed by skin traction, and thirty-one by skeletal traction followed by a cast-brace. The technique of application is described in some detail. The average time for application of the cast-brace was six weeks after the injury, the time in hospital eight weeks and the time till removal fifteen weeks. The patients selected for a cast-brace were in hospital for just over half the time of the others and their fractures on average united more quickly, though with some trouble from angulation of fractures of the uppermost third of the shaft. It is concluded that when used with all the judgment and skill it demands, the cast-brace method is a great advance in conservative treatment

Supination-external rotation (SER) fractures of the ankle may present with a medial ligamentous injury that is not apparent on the initial radiographs. A cadaver gravity-stress view has been described, but the manual-stress view is considered to be the examination of choice for the diagnosis of medial injuries. We prospectively compared the efficacy of these two examinations. We undertook both examinations in 29 patients with SER fractures. Of these, 16 (55%) were stress-positive, i.e. and had widening of the medial clear space of > 4 mm with a mean medial clear space of 6.09 mm (4.4 to 8.1) on gravity-stress and 5.81 mm (4.0 to 8.2) on manual-stress examination, and 13 patients (45%) were stress-negative with a mean medial clear space of 3.91 mm (3.3 to 5.1) and 3.61 mm (2.6 to 4.5) on examination of gravity- and manual-stress respectively. The mean absolute visual analgoue scale score for discomfort in the examination of gravity stress was 3.45 (1 to 6) and in the manual-stress procedure 6.14 (3 to 10). We have shown that examination of gravity-stress is as reliable and perceived as more comfortable than that of manual stress. We recommend using it as the initial diagnostic screening examination for the detection of occult medial ligamentous injuries in SER fractures of the ankle

We report a prospective trial of 66 patients with intraarticular fractures of the calcaneum. All fractures were assessed by CT. Patients with displaced fractures were randomised to receive either conservative (n = 31) or operative treatment (n = 25). Undisplaced fractures (n = 10) were treated conservatively. Operation involved open reduction of the posterior subtalar joint, and fixation with Kirschner wires. All 66 patients were reviewed at a minimum of one year (mean 23 months). After conservative treatment the undisplaced fractures had slightly better results than the displaced fractures. There was no significant difference in outcome between the operatively and the conservatively treated displaced fractures. We have also documented prospectively the natural history of the injury, which is of use in assessing prognosis for both clinical and medicolegal purposes

From 1990 to 1994 we undertook arthroscopy of the ankle on 34 consecutive patients with residual complaints following fracture. Two groups were compared prospectively. Group I comprised 18 patients with complaints which could be attributed clinically to anterior bony or soft-tissue impingement. In group II the complaints of the 16 patients were more diffuse and despite extensive investigation the definitive diagnosis was not clear before arthroscopy. At the time of the fracture, some osteophytes were already present in 41% of the patients. These were related to previous supination trauma and participation in soccer. Arthroscopic treatment consisted of removal of the anteriorly located osteophytes and/or scar tissue. After two years, group I showed a significantly better score for patient satisfaction (p = 0.02). There were good or excellent results in group I in 76% and group II in 43%. Patients with residual complaints after an ankle fracture and clinical signs of anterior impingement may benefit from arthroscopic surgery. The place for diagnostic ankle arthroscopy is limited

A total of 22 patients with a tibial avulsion fracture involving the insertion of the posterior cruciate ligament (PCL) with grade II or III posterior laxity were reduced and fixed arthroscopically using routine anterior and double posteromedial portals. A double-strand Ethibond suture was inserted into the joint and wrapped around the PCL from anterior to posterior to secure the ligament above the avulsed bony fragment. Two tibial bone tunnels were created using the PCL reconstruction guide, aiming at the medial and lateral borders of the tibial bed. The ends of the suture were pulled out through the bone tunnels and tied over the tibial cortex between the openings of the tunnels to reduce and secure the bony fragment. Satisfactory reduction of the fracture was checked arthroscopically and radiographically. The patients were followed-up for a mean of 24.5 months (19 to 28). Bone union occurred six weeks post-operatively. At final follow-up, all patients had a negative posterior drawer test and a full range of movement. KT-1000 arthrometer examination showed that the mean post-operative side-to-side difference improved from 10.9 mm (standard deviation (. sd. ) 0.7) pre-operatively to 1.5 mm (. sd. 0.6) (p = 0.001). The mean Tegner and the International Knee Documentation Committee scores improved significantly (p = 0.001). The mean Lysholm score at final follow-up was 92.0 (85 to 96). We conclude that this technique is convenient, reliable and minimally invasive and successfully restores the stability and function of the knee. Cite this article: Bone Joint J 2015;97-B:1220–5

A prospective study was made over a three-year period of 900 consecutive unilateral Colles' fractures. The radiographic features at the time of fracture, after reduction and one week later were measured and correlated with grip strength and range of movement at three years. The most significant radiographic feature to influence the outcome was the presence of shortening of the radius one week after reduction of the fracture. Persistent dorsal tilt, radiocarpal joint involvement and ulnar styloid fracture were each associated with reduced range of movement, but had no effect on grip strength. Extension of the fracture into the distal radio-ulnar joint was associated with reduced grip strength but had no effect on range of movement. Radial tilt of the radial fragment did not correlate with any aspect of the result after three years

The off-loading characteristics of the cast-braces of 30 patients with fractures of the shaft of the femur have been investigated, during axial loading, using strain-gauge transducers. These were applied at the level of the fracture, where the cast was circumferentially split, and to the hinges of the brace at the knee. They measured the load transferred between the two portions of the thigh cast, and between the thigh cast as a whole and the below-knee cast; by subtraction from the total load on the limb, the skeletal force at the fracture level and at the knee could be calculated. In all patients there was an increase in the fracture load as union progressed which was thought to be due to physiological feedback mechanism from the fracture site. The load carried by the two portions of the thigh cast and by the thigh cast as a whole was proportionately high at first and stabilised at an average of 35 per cent of body weight

1. Loss of osteocytes in the bone trabeculae of the femoral heads of "normal" elderly patients was patchy and distinguishable from that resulting from avascular necrosis after fracture. 2. Changes in the haemopoietic marrow were the earliest and most sensitive indicators of ischaemia, loss of osteocytes rarely being complete until three or four weeks after fracture. 3. In 109 femoral heads removed more than sixteen days after fracture the viability could be determined by histological means. All of these had suffered some damage to the vascular supply but in a number the head remained alive apart from the region of the fracture line. These heads were nourished by the blood vessels of the ligamentum teres and sometimes by retinacular arteries, usually of the inferior group. 4. Some femoral heads became completely necrotic following fracture, others were only partly affected. A variable amount of the subfoveal region commonly remained alive and it was from this site that revascularisation spread into the head. The upper segment of the femoral head least often remained alive and its subchondral region was usually the last to revascularise. 5. In a group of unselected femoral heads a third remained alive following fracture and two-thirds were partly or completely necrotic. 6. Femoral heads which were partly necrotic appeared capable of uniting and completely revascularising, there being invasion of the necrotic bone by vessels from across the fracture line and from the ligamentum teres. This contrasted with the completely necrotic femoral heads described elsewhere in this issue which united but in the absence of proliferation of ligamenturn teres vessels failed to revascularise completely and developed late segmental collapse. 7. Avascular necrosis did not appear to be the sole cause of non-union. 8. Necrotic bone showed no alteration in radiological density. Reossifying bone in areas of revascularisation sometimes caused an absolute increase of radiodensity especially when associated with halted revascularisation. This increase of radiological opacity was the result of deposition of new on dead bone with broadening of the trabeculae. Marrow calcification was minimal. 9. Obliterative sclerosis of venules in the ligamentum teres was found in "normal" patients even in infancy. No thrombosis was seen in the ligaments following fracture but where the femoral heads were completely necrotic and not revascularised the ligaments were often also necrotic. 10. There appeared to be no increase in degenerative changes in the articular cartilage of the femoral heads following fracture compared with fifty elderly controls. Some loss of chondrocytes in the deep zone of the weight-bearing area was found in about a quarter of the femoral heads. In only one head was the cartilage almost completely acellular. An almost normal depth and a smooth contour of the articular cartilage were retained

We describe a method of pinning extension supracondylar fractures of the humerus in children. Following closed reduction, a posterior intrafocal wire is inserted and a second lateral wire added when needed for rotational stability. Between May 2002 and November 2005 we performed this technique in 69 consecutive patients. A single posterior wire was used in 29 cases, and two wires in 40. The mean follow-up was two years (21 to 30 months). The results were assessed according to Flynn’s criteria. In the single-wire group there were 21 excellent, five good and one poor result. Two patients were lost to follow-up. In the two-wire group there were 32 excellent, two good and three poor results. Three were lost to follow-up. The poor results were due to a failure to achieve adequate reduction, fixation or both. We conclude that the intact posterior periosteal hinge can be used successfully in the clinical situation, giving results that compare well with other techniques of pinning. The posterior route offers an attractive alternative method for fixation of supracondylar fractures of the humerus in children

Sixteen patients who underwent a revision operation for nonunion of fractures of the distal humerus following previous internal fixation were reviewed at a mean follow-up of 39 months (8 to 69). The Mayo elbow performance score was excellent in 11, good in two, fair in two and poor in one. In 15 patients union was achieved and in one with an infected nonunion a subsequent bone graft was necessary in order to obtain union. Age, gender, a history of smoking, mechanism of the injury and the AO classification of the initial fracture did not correlate with the development of nonunion. In 12 patients (75%), the initial fixation was assessed as being suboptimal. The primary surgery was regarded as adequate in only three patients. Our findings suggest that the most important determinant of nonunion of a distal humeral fracture after surgery is the adequacy of fixation

A new and simple operative technique has been developed to provide rigid internal fixation for all types of fractures of the scaphoid. This involves the use of a double-threaded bone screw which provides such good fixation that, after operation, a plaster cast is rarely required and most patients are able to return to work within a few weeks. A classification of scaphoid fractures is proposed. The indications for operation included not only acute unstable fractures, but also fractures with delayed healing and those with established non-union; screw fixation was combined with bone grafting to treat non-union. In a prospective trial, 158 operations using this technique were carried out between 1977 and 1981. The rate of union was 100 per cent for acute fractures and 83 per cent overall. This method of treatment appears to offer significant advantages over conventional techniques in the management of the fractured scaphoid

Over an eight-year period up to 1983, a total of 322 consecutive patients had operations for ankle fractures; 176 were Weber type B and 128 type C. We were able to review 230 of these patients after a mean follow-up of six years (1 to 11) including 128 with Weber B and 102 with Weber C fractures. We used an ankle score which combined symptoms and clinical and radiological findings, with a maximum score of 100 points. The mean score for all 230 was 92 (68 to 100). Fifteen of these patients had developed a distal synostosis between the tibia and fibula, three after a Weber B and 12 after a Weber C fracture. In 13 of these 15 ankles the synostosis had been visible radiologically within three months of the operation. In the other two there had been radiologically visible calcification at the three-month follow-up. In 1993, we were able to review nine of the 15 patients with synostosis using the same scoring system. At a mean follow-up of 14 years (12 to 18) the mean score for those with synostosis was 91 (71 to 100), much the same as this group’s previous score and the mean score of the whole group of operated patients. We conclude that distal tibiofibular synostosis after ankle fracture usually causes few symptoms and does not generally require any treatment

Distal femoral physeal fractures in children have a high incidence of physeal arrest, occurring in a mean of 40% of cases. The underlying nature of the distal femoral physis may be the primary cause, but other factors have been postulated to contribute to the formation of a physeal bar. The purpose of this study was to assess the significance of contributing factors to physeal bar formation, in particular the use of percutaneous pins across the physis. We reviewed 55 patients with a median age of ten years (3 to 13), who had sustained displaced distal femoral physeal fractures. Most (40 of 55) were treated with percutaneous pinning after reduction, four were treated with screws and 11 with plaster. A total of 40 patients were assessed clinically and radiologically after skeletal maturity or at the time of formation of a bar. The remaining 15 were followed up for a minimum of two years. Formation of a physeal bar occurred in 12 (21.8%) patients, with the rate rising to 30.6% in patients with high-energy injuries compared with 5.3% in those with low-energy injuries. There was a significant trend for physeal arrest according to increasing severity using the Salter-Harris classification. Percutaneous smooth pins across the physis were not statistically associated with growth arrest

We reviewed the records and radiographs from 10 hospitals to identify 50 patients with rheumatoid arthritis (RA) who had sustained 52 femoral neck fractures. Most patients were female (88%), elderly (mean age 66 years) and had had severe polyarticular disease for a mean duration of 16 years. Over half had taken systemic corticosteroids, nearly all were severely osteopenic but few had rheumatoid changes in the hip. Of the 20 fractures treated by internal fixation 12 had complications including nonunion (5), osteonecrosis (5), infection (1), and intertrochanteric fracture (1). Only one of the nine undisplaced fractures required reoperation, but seven of the 11 displaced fractures had revision surgery. Twenty fractures were treated by primary total hip arthroplasty with only one early complication. The other 12 fractures had been treated by hemiarthroplasty (9), hip excision (1) or non-operatively (2). Our results suggest that, in elderly rheumatoid patients, severely displaced femoral neck fractures should be treated by total hip replacement